NPSF President Testifies Before US Senate Subcommittee on Primary Health and Aging

Panel of Experts Invited to Speak at Hearing on Patient Safety in the US Health System

National Patient Safety Foundation President Tejal K. Gandhi, MD, MPH, CPPS, was among the expert witnesses invited to testify before the Senate Health Education Labor & Pensions (HELP) Subcommittee on Primary Health and Aging at a hearing on July 17 entitled, “More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.”

Dr. Gandhi’s testimony focused on some of the most prevalent and urgent patient safety issues in ambulatory care—medication safety, missed or delayed diagnoses, and safety during transitions in care, such as when patients are discharged from the hospital to home.

“There are numerous ambulatory settings, all with unique safety issues that need more focused attention, because most health care is delivered in these settings,” Dr. Gandhi said. “Most of these settings do not have the type of quality and safety infrastructure that exists in hospitals, nor do they have robust mechanisms to identify errors or measure errors and adverse events.”

Furthermore, Dr. Gandhi said, unlike most hospitals, ambulatory settings are less likely to have dedicated quality and safety personnel or expertise to redesign processes of care to try to prevent errors. She cited a need to develop a more robust ambulatory infrastructure, with mechanisms in place for error reporting, culture change, and safety expertise.

Dr. Gandhi addresses the US Senate Committee on Health, Education, Labor, and Pensions, Subcommittee on Primary Health and Aging,

July 17, 2014

Dr. Gandhi’s recommendations to the committee included identifying better measures of ambulatory safety, increasing research into the sources and prevention of errors in the outpatient setting, and redesigning processes of care to better engage patients and families.

Following the testimony of witnesses, the senators present posed questions that led to a wide-ranging discussion. In response to a question from Sen. Bernard Sanders of Vermont, chairman of the Subcommittee, Dr. Gandhi addressed the importance of increasing transparency in health care, not only between doctors and patients, but between health care institutions.

“One of the areas that I think is a huge missed opportunity is transparency across organizations,” she said. “If my hospital figures out how to solve [an error], that does not naturally leave the four walls of my hospital.” Health organizations would benefit from better mechanisms to share solutions to patient safety issues, Dr. Gandhi said.

The Committee on Health, Education, Labor, and Pensions Subcommittee on Primary Health and Aging oversees long-term care services for older Americans, community health centers, The Health Resources and Services Act, and other policy areas. The testimony of all witnesses, as well as a video replay of the hearing, can be found on the Subcommittee’s website.